Obs&Gynae Flashcards
Take a full gynaecological history
Demographics - name, age, marital status, parity, occupation
Presenting complaint - impact on QoL/normal functioning
Menstrual - LMP, days of bleeding, flow, regularity of cycle, abnormal bleeding (IMB/PCB), menarche
Contraception - current method and duration, previous methods, problems
Cervical smear - last smear and result
Gynae hx - past problems, investigations, treatment, operations
Obs hx - gravidity, parity, outcomes, birth weight, mode of delivery
PMH
DHx + allergies
FH
SH - smoking, alcohol, BMI, HTN
Take a menstrual history
LMP Days of bleeding Flow Regularity of cycle Abnormal bleeding (IMB/PCB) Menarche Impact on QoL/normal functioning
List conditions associated with abnormal menstruation
Amenorrhoea
Dysmenorrhoea
Menorrhagia/dysfunctional uterine bleeding
Describe causes, investigations and management of amenorrhoea
Causes - Turner’s syndrome, endocrine abnormality, pregnancy, lactation, menopause, iatrogenic (progesterone), stress, anorexia, PCOS
Ix - pregnancy test, FSH/LH levels, testosterone/SHBG, prolactin levels, TFTs, pelvic USS, karyotyping
Mx - guided by diagnosis and fertility wishes
Define amenorrhoea
Primary - lack of menstruation by age 16 with secondary sex characteristics, 14 without secondary sex characteristics
Secondary - absence of menstruation for 3 months if regular, 9 months if irregular
Define dysmenorrhoea
Painful periods
Primary - no organic cause
Secondary - due to underlying cause
Describe clinical features, investigations and management of dysmenorrhoea
CFs - functional loss, pelvic pain, deep dyspareunia, PID/STI history, abdominal surgery, abdominal mass, cervical excitation, adnexal tenderness
Ix - STI screen, USS, laparoscopy
Mx - symptom control (paracetamol, mirena IUS, COCP, mefenamic acid), treat cause (COCP/progesterone/GnRH analogue, ABx), therapeutic laparoscopy
Suggest differential diagnoses for dysmenorrhoea
Endometriosis Adenomyosis PID Pelvic adhesions Leiomyomata (fibroids)
Define menorrhagia
Abnormally heavy or prolonged bleeding
Blood loss >80ml
Describe clinical features, investigations and management of menorrhagia
CFs - clots, flooding, anaemia symptoms, disruption of life, enlarged uterus
Ix - FBC, ferritin, TFTs, clotting, STI screen, TVS USS, pipelle biopsy, hysteroscopy
Mx - mirena IUS, transexamic acid, mefanamic acid, COCP, progesterone, GnRH analogue, endometrial ablation, hysterectomy
Suggest differential diagnoses for menorrhagia
Leiomyomata (fibroids) Adenomyosis Endometrial polyps Endometrial hyperplasia Endometrial cancer Hypothyroidism Coagulation disorder Dysfunctional uterine bleeding (dx of exclusion)
Take a sexual history
Partners - gender, type of relationship, duration, number in last 3/12, type of sex, use of barrier contraception Sex with anyone born outside the UK? Been paid/paid for sex? MSM? Sex with bisexual men? Injected drugs? PMH FH DH + allergies Hx of STI Previous HIV tests Menstrual, obstetric, contraceptive, gynae hx
Describe clinical features, investigations and management of acute pelvic pain
CFs - unknown LMP, UPSI, vaginal discharge, bowel/urinary symptoms, acute abdomen, masses, cervical excitation, adnexal tenderness
Ix - urinary/serum b-hCG, urinary MSU, triple swab, FBC, G&S, pelvic USS, diagnostic laparoscopy
Mx - analgesia, treat underlying cause
Suggest differential diagnoses for acute pelvic pain
Gynae - ectopic pregnancy, miscarriage, PID, ovarian cyst rupture/torsion, abscess
Other - appendicitis, IBS, IBD, hernia strangulation, UTI, renal calculi
Define the term chronic pelvic pain
= intermittent or constant pelvic pain in the lower abdomen or pelvis for >6 months, not exclusively with menstruation, intercourse or associated with pregnancy
Suggest differential diagnoses and management of chronic pelvic pain
Gynae - endometriosis, adenomyosis, adhesions (trapped ovary syndrome), pelvic venous congestion
Other - IBS, constipation, hernia, interstitial cystitis, renal calculi, fibromyalgia, nerve entrapment, neuropathic pain
Mx - analgesia, COCP, progesterone, complementary therapy, support groups, GnRH analogue –> hysterectomy
Describe risk factors, clinical features, investigations and management of endometriosis
= retrograde menstruation, sensitive to oestrogen
RFs - early menarche, FH, short menstrual cycles, long duration of bleeding, menorrhagia, defects in uterus/tubes
CFs - cyclical pelvic pain/chronic pelvic pain, dysmenorrhoea, dysuria, dysparaenia, dyschezia, sub fertility, fixed retroverted uterus
Ix - laparoscopy (chocolate cysts, adhesions, peritoneal deposits), pelvic USS
Mx - analgesia, COCP/mirena IUS, surgery (laser ablation)
List different types of ovarian cyst
Non neoplastic:
Functional - follicular, corpus luteal
Pathological - endometrioma (chocolate cyst), polycystic ovaries, theca lutein cyst
Benign Neoplastic:
Epithelial tumour - serous cystadenoma, mucinous cystadenoma, brenner tumour
Benign germ cell tumour - mature cystic teratoma (dermoid cyst)
Sex cord stomal tumour - fibroma, sertoli-leydig cell tumour, thecoma, lipoma
What is Meig syndrome?
Tumour + ascites/pleural effusion
Describe risk factors, clinical features, investigations and management of adenomyosis
= endometrial stroma communicates with myometrium after uterine damage (e.g. pregnancy, childbirth, C-section, TOP), common in posterior wall, responsive to hormones
RFs - high parity, uterine surgery, previous C-section, genetic(?)
CFs - menorrhagia, dysmenorrhoea, deep dyspareunia, irregular bleeding, symmetrically enlarged tender uterus
Ix - TV USS, MRI (*diagnosis is histology after hysterectomy)
Mx - hysterectomy (=curative), NSAIDs, COCP/progesterone, uterine artery embolisation, endometrial ablation
Describe risk factors, clinical features, investigations and management of PID
= infection of upper genital tract in females
RFs - sexually active, intercourse without barrier contraception, STI hx, gynae surgery, TOP, insertion of IUS/IUD
CFs - abdo pain, deep dyspareunia, menstrual disorder (PCB), abnormal vaginal discharge, fever, uterine tenderness, cervical excitation, palpable abdo mass
Ix - endocervical swab (gonorrhoea, chlamydia), high vaginal swab (trichomonas, BV), full STI screen, urine dipstick, pregnancy test, TV USS, laparoscopy
Mx - IM ceftriaxone 500mg STAT + PO doxycycline 100mg BD 14 days + PO metronidazole 400mg BD 14 days
List complications of PID
Tubo-ovarian abscess Fitz-Hugh Curtis syndrome Recurrent PID Ectopic pregnancy Infertility
List different types of urinary incontinence
Stress Urge Mixed Overflow Functional
Describe risk factors, clinical features, investigations and management of stress incontinence
= involuntary leakage during increased intraabdominal pressure
RFs - childbirth, low oestrogen, bladder neck weakness, weak pelvic floor, chronic cough
CFs - coughing, sneezing, exercise = small leak +/- prolapse of urethra and anterior vaginal wall
Ix - urodynamic studies (normal frequency and bladder capacity)
Mx - weight loss, stop smoking, decrease caffeine intake, treat constipation/cough, PT (pelvic floor muscle training), duloxetine, bulking, tape, sling
Describe risk factors, clinical features, investigations and management of urge incontinence
= presence of urgency, usually with frequency and nocturia in the absence of UTI or other pathology
RFs - MS, spina bifida, UMNL, pelvic surgery
CFs - sudden sensation, triggers (running water), leak a large volume
Ix - urodynamic studies (increased frequency, nocturia)
Mx - increase fluid, decrease caffeine, PT (bladder retraining), anticholinergics, oestrogen, botox injection, sacral nerve stimulation, neuromodulation, detrusor myomectomy
List risk factors for prolapse
Pregnancy Vaginal delivery Large baby Instrumental delivery (forceps) Congenital (EDS) Menopause (low oestrogen) Obesity Chronic cough Constipation Iatrogenic (hysterectomy, continence procedures)
Describe the different types of prolapse
Uterine - uterus prolapses down
Rectocele/posterior vaginal prolapse - bulging of the front wall of the rectum into the back wall of the vagina
Cystocele - bladder bulges into vagina anteriorly
Enterocele - herniation of the peritoneal sac containing bowel against vagina
Describe grading of prolapse
Grade 1 - descends halfway down to hymen
Grade 2 - extends to level of hymen
Grade 3 - through hymen, lies outside vagina
Describe clinical features, investigations and management of prolapse
CFs - dragging sensation, discomfort, ‘lump’ coming down, dyspareunia, backache, urinary symptoms (urge, frequency), bowel symptoms (constipation, requires digital assistance), worse with standing, prolapse when asking lady to bear down (using Sims speculum)
Ix - USS, urodynamic studies, ECG, CXR, FBC, U&Es (fitness for surgery)
Mx - lose weight, treat constipation/chronic cough, PT (pelvic floor muscle exercises), pessary, topical oestrogen, surgery (anterior/posterior repair, vaginal hysterectomy)
Define the term infertility
= a couple cannot conceive despite regular unprotected sexual intercourse for >12 months
List different causes of infertility
Primary - premature ovarian failure, genetic (Turner's syndrome), iatrogenic (tubal surgery, chemotherapy), Secondary - PCOS, excessive weight loss/exercise (low BMI), hypopituitarism (tumour, surgery), Kallmann's syndrome, hyperprolactinaemia Ovulation disorder Tubal factor Male factor Endometriosis
Take a fertility history
Age Duration of trying, coital frequency Menstrual hx - LMP, pelvic pain, dyspareunia, cervical smears Obs hx - previous pregnancy (other partner?), ectopic Sexual hx - STIs, PID PMH - tubal/pelvic surgery DH SH - smoking, alcohol, folic acid
Describe clinical features, investigations and management of infertility
CFs - signs of an endocrine disorder (acne, hirsutism, alopecia, acanthosis nigricans), adnexal masses, uterine fibroids, endometriosis, vaginismus
Ix - STI screen, baseline (day 2-5) hormone profile (FSH, LH, FSH, TSH, prolactin, testosterone), rubella status, mid-luteal progesterone level (confirm ovulation), semen analysis, hysterosalpingography (HSG), laparoscopy and dye test, hysterosalpingo-contrast-sonography (HyCoSy)
Mx - healthy diet, stop smoking, no alcohol, exercise, folic acid, regular intercourse, ovulation induction (clomifene), pulsatile GnRH, laparascopic ovarian diathermy, insulin sensitiser, assisted contraception
List the WHO criteria for normal semen analysis
>15 million spermatozoa/ml Sperm volume >1.5ml >39 million spermatozoa/ejaculate pH >7.2 Motility >40% total or >32% progressive >58% live >4% normal morphology
List causes for male infertility
Semen abnormality - testis cancer, drugs (alcohol, nicotine), genetic, varicocele
Azospermia - steroid abuse, Kleinefelter’s syndrome, chemotherapy, cystic fibrosis, STI
Coital dysfunction - hypospadias, phimosis, retrograde ejaculation, MS
Immunological
Describe clinical features, investigations and management of PCOS
= raised GnRH (–> raised LH –> androgens), insulin resistance (–> low SHBG –> androgens), no LH surge (no ovulation)
RFs - diabetes, dysmenorrhoea, FH
CFs - oligo/amenorrhoea, infertility, hirsutism, obesity, chronic pelvic pain, depression, HTN
Ix - basal (day 2-5) LH (high), FSH (normal), TFTs, prolactin, testosterone (high), SHBG (low), oral GTT, pelvic USS (follicles, ovarian volume)
Mx - exercise, orlistat, COCP, progesterone, clomifene +/- metformin, laparoscopic ovarian drilling, antiandrogen
Explain the Rotterdam criteria
= >2/3 for a diagnosis of PCOS
- Irregular/absent periods (cycle >42 days)
- Clinical signs of raised androgens (acne/hirsutism/alopecia)
- Polycystic ovaries on USS (>12 antral follicles), ovarian volume >10ml
List complications of PCOS
Gestational DM
Endometrial hyperplasia
Suggest differential diagnoses for bleeding/pain in early pregnancy
Miscarriage Ectopic pregnancy Gestational trophoblastic disease Hyperemesis gravidarum Placental issues
Define the term miscarriage?
= a loss of a pregnancy <24 weeks of gestation
Early - <12-13 weeks
Late - 13-24 weeks
Describe the classification of miscarriage
Threatened - blood +/- pain, closed Os
Complete - symptoms cease, closed Os, empty uterus
Incomplete - blood +/- pain, possible open Os, tissue in uterus
Missed - no fetal heart activity, closed Os
Inevitable - blood +/- pain, open Os
PUL - +ve pregnancy test, empty uterus, closed Os
When is Anti-D prophylaxis given?
Any sensitising event:
<12 weeks - uterine evacuation, ectopic
>12 weeks - if bleeding
Describe clinical features, investigations and management of miscarriage
RFs - maternal age >30-35, previous miscarriage, obesity, chromosomal abnormality, smoking, uterine abnormality, antiphospholipid syndrome
CFs - PV bleed +/- clots, suprapubic, cramp pain, haemodynamic instability, distended tender abdomen, diameter of cervical os, uterine tenderness
Ix (at EPAU) - TV USS (CRL, fetal pole, mean sac diameter), serum bHCG, FBC, Rh status
Mx - anti-D prophylaxis
Conservative - repeat scan in 2/52, pregnancy test in 3/52
Medical - mifepristone + misoprostol, pregnancy test in 3/52
Surgical - manual vacuum, ERPC
List advantages and disadvantages of the types of miscarriage management
Conservative:
+ - home, no surgical risk
- - unpredictable timing, blood, pain, unsuccessful
Medical:
+ - home, no surgical risk
- - s/e of medication (diarrhoea, vomiting), blood, pain, unsuccessful
Surgical:
+ - planned procedure, general anaesthetic
- - anaesthetic risks, infection (endometritis), uterine perforation, bladder/bowel damage, retained POC, Asherman’s syndrome (intrauterine adhesions)
Describe causes, investigations and management of recurrent miscarriage
= >3 consecutive pregnancies that end in miscarriage before 24 weeks gestation
Causes - antiphospholipid syndrome, genetics (parental/embryonic), endocrine (diabetes, thyroid, PCOS), anatomical (uterine malformation, cervical weakness), infective (BV), inherited thrombophilia
RFs - increased maternal age, miscarriage hx, lifestyle (smoking, alcohol, caffeine)
Ix - bloods (antiphospholipid antibody, thrombophilia screen, karyotyping), imaging
Mx - counselling, specialist miscarriage clinic, clinical geneticist, cervical cerclage, heparin, low dose aspirin
Describe clinical features, investigations, management and complications of ectopic pregnancy
= implantation of a conceptus outside the uterine cavity
RFs - previous ectopic, PID, endometriosis, IUD/IUS/POP/implant, tubal ligation/occlusion, pelvic surgery, assisted reproduction (IVF)
CFs - lower abdomen pain +/- blood PV, shoulder tip pain, brown vaginal discharge, abdo tenderness, cervical tenderness, adnexal tenderness, haemodynamically unstable
Ix - pregnancy test (urine hCG), pelvic USS/TV USS, serum bHCG
Mx - Anti-D, A-E if unstable
Medical - IM methotrexate (*contraception for 3 months required)
Surgical - lap. salpingectomy/salpingotomy
Conservative - monitor serum b-hCG (48hrly)
Complications - fallopian tube rupture, peritonitis, sepsis
Describe clinical features, investigations and management of gestational trophoblastic disease
RFs - maternal age <20 ir >35, previous disease, previous miscarriage, use of OCP
CFs - abdo pain +/- PV bleed, large for dates uterus, soft boggy uterus, hyperemesis, hyperthyroidism, anaemia
Ix - urine/blood b-hCG, USS (snowstorm/whirlpool appearance surrounding multiple cysts), MRI/CT/USS (suspected metastatic spread)
Mx - register with GTD centre, suction curettage/medical evacuation, anti-D, chemo +/- surgery
State the triad of gestational trophoblastic disease
> 5% weight loss
Dehydration
Electrolyte disturbance
Suggest differential diagnoses for postmenopausal bleeding
= vaginal bleeding >12 months after periods have stopped Endometrial cancer Endometrial hyperplasia Atrophic vaginitis/endometrial atrophy Endometrial polyps
Describe clinical features, investigations and management of endometrial cancer
= presence of unopposed oestrogen (endogenous/exogenous)
RFs - obesity, T2DM, hypothyroidism, low progesterone production (nulliparity, PCOS, early menarche, late menopause), genetic (HNPCC/Lynch syndrome), breast cancer, HRT, tamoxifen
Protective factors - COCP, parity
CFs - PMB, menstrual disturbance (heavy, irregular), PV discharge
Ix - FBC, LFTs, U&Es, TV USS +/- biopsy, CT CAP (staging)
Mx - surgery (TAH & BSO), adjuvant radiotherapy, hormonal (high dose progesterone = palliation of bleeding symptoms), palliative radiotherapy
Explain the different types of HRT as well as their advantages and disadvantages
Oetrogen + progesterone/oestrogen only (if hysterectomy)
Continuous/cyclical
PO, transdermal (patch, gel), PV (cream, pessary), implant
+ - alleviate menopausal symptoms (hot flushes, vaginal dryness, night sweats)
- - increased risk of breast cancer, endometrial cancer (if oestrogen only), blood clots
What is CIN?
= precursor lesion for carcinoma of cervix
Which HPV infections are associated with the development of CIN and cervical cancer?
HPV 16, 18, 31, 33
List risk factors for cervical cancer
Persistent high risk HPV infection Multiple partners Smoking Immunosuppression COCP use
Explain the criteria for cervical screening
Sexually active women aged 25-64
3 yearly for women aged 25-50
5 yearly for women aged 50-64
List indications for referral to colposcopy
Smear showing borderline nuclear changes or mild dyskaryosis with high risk HPV
Smear showing moderate or severe dyskaryosis
Smear suggestive of malignancy
Smear suggestive of glandular abnormality
Three consecutive inadequate smears
Keratinizing cells
Post coital bleeding
Abnormal looking cervix
Describe the management of CIN
Depends on grade and patient preference
Conservative
Excision
Destruction
Describe the indications, benefits and complications of LLETZ excision
= large loop excision of transformation zone
Persistent low grade low grade CIN (CIN 1)
High grade CIN (>CIN 1)
+ - easy, safe, local anaesthetic, tissue available for histology/assessment of excision margins
Complications - haemorrhage, infection, vaso-vagal reaction, anxiety, cervical stenosis (dysmenorrhoea), cervical incompetence, premature delivery
State the % of low grade CIN that will regress
50-60% spontaneously regress within 2 years
State the % of high grade CIN that will progress to cancer within 10 years
CIN 2 - 3-5%
CIN 3 - 20-30%
Describe the risk factors, clinical features and management of vaginal/vulval cancer
Rare (<1 in 100)
RFs - age (>60), HPV, HIV, smoking
CFs - itching, bleeding, discharge
Mx - wide local excision, vulvectomy, groin lymphadenopathy +/- radiotherapy
Describe the clinical features and management of lichen sclerosis
Potential to progress to SCC
CFs - itching, white atrophic patches, fusion, adhesions
Mx - topical steroids, regular follow up
Describe clinical features, investigations and management of cervical cancer
= persistent infection with high risk HPV, age 45-55
RFs - exposure to HPV (early first sexual experience, multiple partners, non barrier contraception), smoking, immunosuppression
CFs - detection on cervical smear, PCB, PMB, heavy bleeding PV, weight loss, fistula, roughened hard cervix +/- loss of fornices, fixed
Ix - colposcopy punch biopsy (irregular surface, abnormal vessels, dense aceto-white changes), U&Es, LFTs, FBC, CT CAP, MRI pelvis, examination under anaesthetic
Mx - (depends on stage and age), local excision/TAH, lymphadenopathy + Wertheim’s hysterectomy, chemotherapy, combination chemoradiotherapy, best supportive care, palliative radio
List complications of cervical cancer
Bleeding Infection DVT/PE Ureteric fistula Lymphoedema Acute bowel/bladder dysfunction Vaginal stenosis
Describe the common histology of cervical cancer
SCC (85-90%)
Adenocarcinoma (10-15%)
Describe clinical features, investigations and management of ovarian cancer
= irritation of ovarian surface epithelium by damage during ovulation, age 60-70
RFs - multiple ovulations, nulliparity, early menarche, late menopause, genetics (BRCA mutations, HNPCC (Lynch)
CFs - abdominal distension (bloating), urinary symptoms, change in bowel habit, abnormal PV bleeding, pelvic mass, ascites, omental mass, pleural effusion, supraclavicular lymphadenopathy
Ix - FBCs, U&Es, LFTs (albumin), Ca125, CEA, Ca19-9, AFP, hCG tumour markers. abdo/pelvic USS, CXR, CT CAP
Mx - staging laparotomy, debulking surgery, hysterectomy, BSO, omentectomy, lymph node sampling, peritoneal biopsy, pelvic wash, adjuvant chemotherapy (platinum agents)
Which cancers is someone with BRCA predisposed to?
Ovarian
Breast
Which cancers is someone with HNPCC (Lynch II syndrome) predisposed to?
Colorectal
Uterine
Ovarian
List protective factors for ovarian cancer
Suppressed ovulation
COCP use
Pregnancy
What is the purpose of a sexual health history?
Assess clinical condition
Assess risk for STIs (including HIV) - which sites to test, when to test
Assess risk of pregnancy/need contraception
What is the window period for chlamydia/gonorrhoea testing?
2 weeks
What is the window period for HIV?
4 weeks
What is the window period for Hepatitis B?
12 weeks
What is the window period for Syphilis?
12 weeks
What is the window period for Hepatitis C?
6 months
List causes of vaginal discharge
Physiological - pregnancy, sexual arousal, menstrual cycle variation
Pathological - vaginal (candida, trichomoniasis, FB, post menopausal vaginitis), cervical (gonorrhoea, herpes, cervical ectropion, cervical neoplasm)
Describe clinical features, investigations and management of vulvovaginal thrush
RFs - ABx use, steroids, immunosuppression
CFs - superficial dyspareunia, itch, white curd-like discharge
Ix - satellite lesions –> candida albicans
Mx - anti fungal (PV, PO, topical)
Describe clinical features, investigations and management of bacterial vaginosis
CFs - thin, white/grey fishy smelling discharge
Ix - odour with KOH whiff test, clue cells on high vaginal swab (*Amsel criteria) –> gardnerella vaginalis
Mx - metronidazole PO
Describe clinical features, investigations and management of trichomonas vaginalis
CFs - itchy/sore, frothy offensive odour discharge, UPSI (vaginal)
Ix - strawberry cervix –> protozoan
Mx - metronidazole PO
List common symptoms of pregnancy
Nausea Vomiting Increased frequency of urination Breast tenderness Fetal quickening (first baby = 18-20, multiple = 16-18)
List components of a booking visit
Folic acid 400mcg daily (or 5mg), vitamin D, iron Aspirin 75mg (pre-eclampsia risk) Food hygeine Lifestyle advice (smoking, drugs, alcohol) Exercise - pelvic floor Breastfeeding Antenatal classes Antenatal screening Mental health issues Weight/height (BMI) Rule out FGM Domestic violence Haemoglobinopathy (sickle cell, B thal), anaemia Blood group Infection (syphillis, hepatitis, HIV, rubella) Urine - blood, glucose, protein
List prenatal screening tests available in the UK
Fetal anomaly USS - 18+0-20+6 weeks
Down’s - 13+6
Describe the different Down’s screening tests
12 weeks - combined test (NT, b-hCG, PAPP-A)
<20 weeks - quadruple test (b-hCG, aFP, uE3, inhibin A)
State examples of confirmatory diagnostic tests for Down’s and when they can be performed
Chorionic villus sampling - 10-12 weeks
Amniocentesis - 16-18 weeks
State the frequency of antenatal appointments and what is monitored
Uncomplicated nulliparous = 10 with midwife
Uncomplicated parous = 7
BP, urine, symphysis-fundal height (>24 weeks), fetal presentation (>36 weeks)
List physiological changes of pregnancy
CVS:
BP low in T1+T2, normal in T3, high blood volume, CO, SV, HR, decreased systemic vascular resistance
Coagulation:
Prothrombotic state *VTE prophylaxis
Low flow velocity to lower limbs, increased factor 7,8 fibrinogen, vWF
Increased inhibition of fibrinolysis
State the most likely place for a DVT in a pregnant woman and why
Left leg
Due to compression of left iliac vessel by right iliac artery and ovarian artery which only crosses vein on left side
Ileofemoral
*if acute VTE, treat with LMWH
Describe clinical features, investigations and management of pre-eclampsia
= new onset HTN (>140/90) and proteinuria (>300mg/24h) in the second half of pregnancy that resolves after delivery
CFs - headache, visual disturbance, epigastric pain (RUQ), oedema, vomiting, hyperreflexia/clonus, epigastric tenderness, abnormal bloods (raised urea, creatinine, rate, ALT, low platelets)
Ix - maternal BP, proteinuria, platelet count, LFTs, fetal movements, CTG, umbilical doppler, US (fetal size, liquor volume)
Mx - check BP in T1, monthly visits (>20 weeks), fortnightly visits (>34 weeks), early intervention if BP >140/90, *admit if persistent >170/110/persistent >140/90 + proteinuria, methyldopa, labetalol, nifedipine
Describe the pathogenesis of pre-eclampsia
Abnormal trophoblastic invasion and adaptation of spiral arteries –> low vasodilators –> maternal plasma volume fails to expand –> placenta fails to be a low pressure system
List complications of pre-eclampsia
CNS - intracranial haemorrhage/cortical blindness
Renal - renal tubular necrosis
Resp - pulmonary oedema
Liver - haemorrhage, hepatic rupture, HELLP, DIC
Placenta - placental infarction/abruption
Fetus - death, IUGR, preterm, cerebral palsy
Describe primary and secondary prevention of pre-eclampsia
Primary - rest, exercise, diet/nutrition (vit. D, calcium), low dose aspirin
Secondary - labetalol, methyldopa, nifedipine SR, daxazocin
*in emergency –> hydrazine/labetalol/nifedipine SR
*prevent fits with magnesium
List contraindications for labetalol
T1DM
Asthma
Phaeochromocytoma
What is eclampsia?
= generalised convulsions during pregnancy, labour or <7 days post partum
Not caused by epilepsy or another neurological disorder
List risk factors for gestational diabetes
BMI >30kg/m2 Previous macrosomic baby (>4.5kg) Previous GDM First degree relative with diabetes Ethnicity - south asian, black caribbean, middle eastern Current large for dates fetus
Describe the diagnosis of gestational diabetes
Oral glucose tolerance test at 26-28 weeks (*may be repeated at 34 weeks if concerns)
75g glucose
Fasting glucose >5.6mmol/L
2h plasma glucose >7.8mmol/L
Describe management of gestational diabetes
MDT - obstetrician, diabetologist
Measure glucose 4-6x day (1h post prandial)
Lifestyle change (diet –> metformin –> insulin)
Fetal monitoring USS 4 weekly (from 28 weeks)
Birth planning - no later than 40+6
State information to give to a mother with GDM post-partum
Check glucose prior to discharge
OGTT 6 weeks post partum
50% risk of T2DM in next 25 years
Describe types, causes and complications of breech presentation at term
Types - extended/frank, flexed/complete, footling
Causes - idiopathic, preterm, previous breech, uterine abnormalities, placenta praaevia, metal abnormalities, multiple
Complications - fetal hypoxia, trauma at labour, preterm, C-section delivery
Describe indications and complications of external cephalic version
= manually turning fetus from 37 weeks
Contraindications - CS delivery already indicated, antepartum haemorrhage, fetal compromise, oligohydramnios, pre-eclampsia
Define zygocity
= the number of ova from which a pair of twins are derived –> monozygotic/dizygotic
Define chorionicity
= the number of placenta –> monochorionic/dichorionic
List differentials for antepartum haemorrhage
= bleeding >24 weeks gestation before onset of labour Placental abruption Placenta praevia Polyps Ectropion
Define primary and secondary postpartum haemorrhage
Primary = blood loss >500ml within 24h of delivery Secondary = excessive loss 24h-6 weeks after delivery
List causes of primary postpartum haemorrhage
4Ts Tone - uterine atony Tissue - retention of placental tissue Trauma - vaginal/cervical tears Thrombin - coagulopathies and vascular abnormalities - placental abruption, HTN, pre-eclampsia, vWF, haemophilia, ITP, DIC, HELLP
Describe risk factors, clinical features, investigations and management of postpartum haemorrhage
RFs - maternal age >40, BMI >35, asian ethnicity, multiple pregnancy, fatal macrosomia, placental problems, IOL, prolonged labour, instrumental delivery, CS delivery, episiotomy
CFs - PV bleed, dizzy, SOB, palpitations, uterine rupture, missing cotylydon
Ix - FBC, X-match, coagulation profile, U&Es, LFTs
Mx - resus, treat cause, bimanual compression, balloon tamponade, haemostatic suture, hysterectomy, IV oxytocin, manual removal with anaesthetic, prophylactic ABx, repair laceration/laparotomy/hysterectomy, blood products
List causes of secondary postpartum haemorrhage
Uterine infection
Retained placental tissue
Abnormal involution of placental site
Trophoblastic disease
Describe clinical features, investigations and management of secondary postpartum haemorrhage
CFs - PV bleed, fever/rigors, lower abdomen pain/tenderness, high uterus
Ix - high vaginal swab, bloods (culture, FBC, U&Es, CRP, coagulation profile, G&S), pelvic USS
Mx - ABx, uterotonics, surgery (e.g. balloon catheter)
Describe clinical features, investigations and management of obstetric cholestasis
= raised in asians, trimester 3, resolves after delivery
CFs - pruritus of trunk, limbs, hands, feet without skin rash, worse at night, loss of appetite, jaundice
Ix - LFTs (high ALT, AST, GGT, ALP), clotting, raised bile acids, viral serology, autoimmune screen, USS of liver and biliary tree
Mx - consultant led care, 1-2weekly LFTs, water soluble vit. K, topical emollients, ursodeoxycholic acid, fetal surveillance (USS/CTG)
List risk factors of perinatal psychiatric
Personal MH history Other vulnerability factors (substance misuse, domestic violence) FH of bipolar disorder <16 years old Unrealistic ideas of motherhood Pre-existing illness FH Volatile/absent family relationships Social isolation Pregnancy complications Social problems
List screening tools for postnatal depression
Edinburgh’s PND scale
GAD-2
Beck’s Depression Inventory
Describe onset and management of postpartum blues
3-10 days post partum
Self limiting (48h-2 weeks)
Reassurance essential
Describe onset and management of postnatal depression
1-3 weeks post delivery or 10th-12th
NICE screening Qs/EPND scale
Mild/moderate - self help strategies
Moderate/severe - CBT, antidepressants (SSRI sertraline)
Describe onset and management of puerperal psychosis
Abrupt onset (1st week)
*refer to specialist perinatal service (+mother/baby unit) - increased risk of suicide, infanticide
Antipsychotics/lithium/ECT
Define the first stage of labour
Latent - cervix effacement +3cm dilation
Active - cervix dilation 3-10cm
What is the rate of progression of the first stage of labour
Prima - 0.5cm dilation/hr
Multi - 1cm dilation/hr
List monitoring recorded on partogram
FHR (every 15 mins/continuous) Contractions (30 mins) Maternal pulse (1hrly) BP/temp (4hrly) Vaginal examination (4hrly)
Describe the modified bishop score
= assess favourability for IOL (>8 = favourable cervix) Dilation Length of cervix Station (relative to ischial spines) Consistency Position
List indications for induction of labour
Obstetric - uteroplacental insufficiency, prolonged pregnancy (41-42 weeks), IUGR, oligohydramnios, non reassuring CTG, PROM, severe pre-eclampsia, unexplained antepartum haemorrhage, chorioamniotits
Medical - severe HTN, uncontrolled diabetes, renal disease with decreased renal function
List methods of IOL
Amniotomy + oxytocin infusion
Vaginal PGs
Membrane sweep
List contraindications for IOL
Major placenta praaevia Vasa praevia Cord prolapse Transverse lie Active genital herpes Previous CS delivery
List complications of IOL
Failure Infection Uterine hyperstimulation (*give terbutaline) Pain Cord prolapse Increased risk of further interventions
Describe how to interpret a CTG
Dr C Bravado Define Risk Contractions /10 mins - normal <5 Baseline Rate - normal 110-160 Variability >5bpm - normal 5-25bpm Accelerations (with movements/contractions are reassuring) Decelerations - early/variable/ late Overall assessment
Describe classification of CTG
Reassuring/non-reassuring/abnormal
Normal/suspicious/pathological
List indications for instrumental delivery
FORCEPS: Fully dilated cervix Obstruction excluded Ruptured membranes Contracting uterus Engagement of head at/below ischial spines Presentation suitable Severity of pain reduced (epidural)
